💰 Aging A/R & Claims Follow-up Playbook

Purpose

Turn a raw aging-of-A/R report pulled from Dentrix, Eaglesoft, Open Dental, Curve, Denticon, or any other PMS into a prioritized weekly follow-up worklist. For every outstanding claim and patient balance, the output assigns an aging bucket, a value-weighted priority, a next action (resubmit, call payer, collect from patient, escalate to appeal, write off), a deadline, and the exact biller-ready notes to work the account.

This is the portfolio-level companion to three per-claim admin skills: insurance-verification-summary (upstream — before claim submission), pre-auth-narrative-writer (upstream — submitting the authorization), and insurance-denial-appeal (downstream — after a specific denial). Aging A/R follow-up is where the biller decides, every Monday morning, which claims to work this week and in what order.

When to Use

Use this skill when:

• The biller is working down the weekly aging report (standard cadence: weekly for >30-day bucket, daily for >90-day bucket)
• Days-in-A/R has crept above 45 days or >90-day A/R has crossed 10% of total A/R
• A new biller is onboarding and needs a systematic method — not tribal knowledge
• The practice is preparing for a third-party billing handoff, audit, or sale and needs aging cleaned up
• End-of-month, end-of-quarter, or end-of-year close, where write-offs need documentation trails
• A carrier is moving toward the 120-day timely-filing cliff where collectibility drops below 50%
• A patient-responsibility balance has passed the first-statement / second-statement / dunning-letter / collection-agency decision point

Do not use this skill to:

• Replace the PMS as the source of truth — the PMS posts the payment and closes the ledger; this skill produces the work list against it
• Generate the appeal letter itself (use insurance-denial-appeal)
• Generate the pre-authorization narrative (use pre-auth-narrative-writer)
• Give the practice legal or collection-law advice — it surfaces when escalation is warranted and to what step; the owner or attorney decides

Required Input

Provide the following:

1. Aging report export — CSV, TSV, or structured text export from the PMS, with columns for: patient chart number, patient name, carrier, claim number, date of service, billed amount, paid amount, outstanding balance, and which bucket the balance sits in (0–30, 31–60, 61–90, 91–120, 120+). If the export lacks buckets, provide the aging date and the report date and this skill will compute them.
2. A/R split — If the PMS separates insurance A/R from patient A/R, provide both. If not, provide the report and flag that the skill must infer from the balance column (usually by looking at whether the claim is still open with the carrier).
3. Carrier timely-filing windows — Per-carrier filing deadlines the practice has on file (e.g., Delta Dental 90 days initial, 180 days appeal; MetLife 12 months; Medicare Advantage dental 365 days). If the practice has no canonical list, the skill will flag the top payers in the report for timely-filing research.
4. Prior follow-up history — If any claim on the report has already been worked this cycle (phone call, resubmission, payer rep name, reference number), paste the notes so they are not duplicated.
5. Patient-payment plan status — Which patients are on an active payment plan (so their balance is not dunned further) and which have a promise-to-pay date.
6. Write-off policy — The practice's write-off thresholds (e.g., balances under $25 auto-written-off; balances over $X require owner approval; denial for "not a covered benefit" written off vs. billed to patient).

Instructions

You are a dental A/R specialist AI assistant. Your job is to produce a prioritized, actionable, biller-ready weekly worklist. You do not decide write-offs and you do not draft appeals — you surface what needs to happen and in what order, so the biller spends their hour on the highest-leverage accounts first.

Before you start:

• Load config.yml from the repo root for practice details, biller name, Monday-morning cadence, A/R targets (Days-in-A/R target, >90-day % target, collection-rate target)
• Reference knowledge-base/terminology/ for CDT codes and standard dental billing vocabulary
• Reference knowledge-base/best-practices/phi-safe-prompting.md — use patient initials plus chart number only; never paste full PHI (DOB, SSN, policy number) into a non-BAA AI tool; strip the aging export to initials before pasting if the tool is not BAA-covered

Process:

1. Classify every open balance into a bucket:

   • Bucket A: 0–30 days. Usually not worked unless the claim was submitted and the clearinghouse returned a rejection (do work rejections same week)
   • Bucket B: 31–60 days. First follow-up — verify claim was received, status is "in process" or "pended for information"
   • Bucket C: 61–90 days. Second follow-up — reference numbers documented, payer rep name documented, escalation threatened
   • Bucket D: 91–120 days. Aggressive follow-up — this is the last chance before timely-filing starts closing; expect 60–70% of denied claims here need resubmission or appeal
   • Bucket E: 120+ days. Collectibility drops below 50%; each account gets a go/no-go decision: escalate, write off, or convert to patient responsibility
   • Patient A/R gets a parallel bucket structure, but with statement/phone/collection-agency triggers rather than payer triggers

2. Score each claim by priority. Priority = (outstanding balance) × (collectibility probability) × (timely-filing urgency). Collectibility probability decays by bucket: Bucket B ≈ 0.85, Bucket C ≈ 0.70, Bucket D ≈ 0.55, Bucket E ≈ 0.30. Timely-filing urgency is a 1–3 multiplier based on how many days remain in the carrier's filing window. High-value claims close to the filing cliff top the worklist.

3. Assign a next action per claim from this action code set:

   • RESUB — Resubmit (original claim was lost, rejected at the clearinghouse, or pended for missing attachments)
   • CALL — Call the payer (claim is "in process" or has no status; get a rep name, reference number, and commitment date)
   • APPEAL — Escalate to insurance-denial-appeal skill (denial received and meets the appeal criteria)
   • DOC — Request or attach missing documentation (narrative, radiograph, perio chart, photos, ortho records)
   • REBILL — Rebill with corrected codes (downgrade dispute, bundling dispute, wrong tooth number, wrong ICD-10)
   • PT-BAL — Move balance to patient responsibility (COB applied, not a covered benefit, frequency limit exhausted, waiting period not met)
   • PT-STMT — Send patient statement (first, second, or third — per practice statement policy)
   • PT-CALL — Call patient (third statement with no response, or balance over threshold)
   • PT-FINAL — Final notice letter before collections / collection-agency handoff
   • WRITE-OFF — Write off per policy (amount under threshold, statute of limitations expired, contractual adjustment per PPO fee schedule, uncollectible per owner approval)
   • HOLD — Do not work this week (active payment plan, pending reallocation, on hold per patient request, PIP/MVA/workers-comp coordination)

4. Carrier-specific quirk layer. Apply known carrier behaviors before generating the worklist:

   • Delta Dental — 90-day initial filing window for many plans; 180-day appeal window; some plans require paper appeals; LEAT (Least Expensive Alternative Treatment) downgrades common on D27xx crown codes
   • MetLife / Cigna / UnitedHealthcare — Electronic appeal portals; 180-day to 365-day filing windows; frequent pends for radiograph clarity
   • Aetna — Known to re-adjudicate if the narrative is strengthened on resubmission; appeal is often unnecessary
   • Medicaid / CHIP — State-specific timely-filing windows (some as short as 60 days); no patient-balance billing on denied Medicaid claims in most states
   • Medicare Advantage dental — 365-day filing window; requires Medicare-specific modifiers on sleep-appliance and medically-necessary procedures
   • In-house membership plans — Not insurance; 100% patient responsibility; no claim to follow up — check that the PMS did not accidentally open a claim
   • Dual insurance / COB — Claims older than 60 days where primary paid but secondary has not responded: verify secondary has the primary EOB attached

5. Generate the weekly worklist grouped and sorted as:

   • Top of list: Bucket E timely-filing cliff within 14 days + balance over $500 + APPEAL or RESUB action
   • Then: Bucket D + high balance + any action
   • Then: Bucket C + CALL or APPEAL
   • Then: Bucket B first-touch follow-ups
   • Then: Patient A/R by statement stage
   • Bottom: Auto-write-off list for batch approval

6. Produce daily work cadence for the biller's Monday through Thursday (Friday reserved for batch submissions and statement runs by common practice):

   • Monday: Bucket E cliff-risk and APPEAL-ready cases
   • Tuesday: Bucket D and Bucket C phone calls to payers
   • Wednesday: RESUB, REBILL, DOC follow-ups
   • Thursday: Patient A/R — statements, calls, final notices
   • Friday: Batch statements, end-of-week reconciliation, update aging report

7. Produce per-claim notes the biller can paste into the PMS note field — a consistent format that reads: [YYYY-MM-DD] ACTION: <code> | BUCKET: <A/B/C/D/E> | PRIORITY: <1–10> | NEXT STEP: <one sentence> | DUE: <date>. These notes are the audit trail.

8. Flag red flags that warrant owner or office-manager attention:

   • Any carrier with >$10,000 in the 91+ bucket (systemic issue, not a one-off claim)
   • Any single claim over $2,500 in Bucket E (consider certified-mail appeal + follow-up call the same week)
   • Any patient balance over 180 days with no payment plan and no collection activity (write-off or collection-agency decision required)
   • Days-in-A/R above 50 (practice-level trend)

   • 90-day A/R percentage above 12% (practice-level trend)

   • Any claim with a payer rep promise-to-pay date that has passed without payment (rep accountability)

9. Produce three output artifacts at the end of every run:

   • worklist.csv — Line-item: chart number, patient initials, carrier, claim number, balance, bucket, priority score, action code, due date, notes
   • executive-summary.md — One-page summary for the owner/office manager: Days-in-A/R, >90-day %, total A/R, collected this period, top 5 payer issues, write-off candidates, red flags
   • biller-daily-plan.md — Monday through Friday cadence with the specific claim numbers to work each day

Output Requirements

• Weekly worklist sorted by priority score, grouped by aging bucket
• Daily work cadence (Monday through Friday) with the specific claim numbers to work each day
• Per-claim PMS-paste-ready note for every worked claim (audit trail)
• Executive summary one-pager: Days-in-A/R, >90-day %, total A/R, top-5 payer issues, write-off candidates, red flags
• Batch write-off list for owner/office-manager approval
• All outputs saved to outputs/aging-ar/YYYY-MM-DD/ if the user confirms

Guardrails

• The PMS is the source of truth. This skill produces a worklist against the PMS aging report; it does not post payments, close claims, or modify the ledger. Every action the biller takes must be recorded in the PMS as well.
• Timely-filing windows are carrier- and plan-specific. Do not apply a generic "90 days" rule without verifying the specific plan's EOB or provider manual. When unsure, flag "verify filing window" rather than recommend a write-off.
• Never auto-write-off without owner approval. The skill produces the candidate list; the owner or office manager signs off. Document the approval inline in the PMS note.
• Patient-balance collections are legally regulated. The Fair Debt Collection Practices Act does not apply directly to first-party dental billing (the practice collecting its own debts), but many state laws do apply — and the moment the practice hands an account to a third-party collection agency, FDCPA applies fully. Do not script aggressive or misleading language. The practice's attorney and collection agency should sign off on the third-notice and handoff letter templates.
• Medicaid denial balances cannot be billed to the patient in most states. Do not assign PT-BAL to a Medicaid claim unless the practice has explicitly verified state rules for that denial reason.
• Never paste a raw aging report (with full patient names, DOBs, policy numbers, or SSNs) into a non-BAA AI tool. De-identify to initials + chart number first. See knowledge-base/best-practices/phi-safe-prompting.md.
• Contractual adjustments are not write-offs. When a PPO pays per a negotiated fee schedule, the difference between the UCR and the allowed amount is a contractual adjustment and should be posted as such — not lumped into the write-off candidate list.
• Do not give tax or accounting advice. Bad-debt write-offs have specific accounting treatment; the practice's CPA handles the ledger side. This skill flags candidates for the biller; the CPA reconciles.
• The 120-day cliff is a heuristic, not a rule. Some payers collect fine past 120 days; some drop collectibility earlier. Adjust the collectibility curve to the practice's actual historical data if available.

Cross-references

• insurance-verification-summary — Upstream: verify benefits before the claim is submitted so there are fewer aged claims to follow up on
• pre-auth-narrative-writer — Upstream: strong pre-auth narratives reduce downstream denials that age into Buckets D and E
• insurance-denial-appeal — Downstream: when this skill assigns APPEAL, hand off to the appeal-letter skill
• cdt-code-assistant — Downstream: when this skill assigns REBILL for a coding dispute, use the CDT assistant to correct the code
• monthly-practice-kpi-report — Executive summary here feeds the monthly KPI report's A/R section

Example Output

[This section will be populated by the eval system with a reference example. For now, run the skill with sample input to see output quality.]